county of los angeles probation department
TRANSCRIPT
COUNTY OF LOS ANGELES PROBATION DEPARTMENT
Rebuild Lives and Provide for Healthier and Safer Communities
9150 EAST IMPERIAL HIGHWAY – DOWNEY, CALIFORNIA 90242 (562) 940-2501
ADOLFO GONZALES Chief Probation Officer
April 13, 2021
To: Supervisor Hilda L. Solis, Chair Supervisor Holly J. Mitchell Supervisor Sheila Kuehl Supervisor Janice Hahn Supervisor Kathryn Barger
From: Adolfo Gonzales Chief Probation Officer
DELIANN-LUCILLE ACHIEVEMENT HOME SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM (STRTP)
CONTRACT COMPLIANCE REVIEW
REVIEW OF REPORT
Probation Child Welfare (PCW) Residential Program Monitoring (RPM), under Placement Permanency and Quality Assurance (PPQA), conducted a Contract Compliance Review of the Deliann-Lucille (DeliLu) Achievement Home Short-Term Residential Therapeutic Program (Contractor) in March 2020. The Contractor has three (3) offices located in the Second Supervisorial District. Each site provides services to the County of Los Angeles Probation foster children, Los Angeles County Department of Children and Family Services (DCFS) foster children, children placed by other counties, and Non-Minor Dependents (NMDs). Due to the onset of the COVID-19 pandemic, there were multiple delays during this review.
Key Outcomes
NUMBER OF PRIORITY FINDINGS
PRIORITY 1 3
PRIORITY 2 19
PRIORITY 3 1
Each Supervisor April 13, 2021 Page 2 of 4
The Contractor was in full compliance with two (2) of 10 applicable areas of RPM Contract Compliance Review: General Contract Requirements and Health and Medical Needs. There were deficiencies noted in eight (8) of 10 applicable areas with 23 deficiencies out of 84 elements.
For the purpose of this review, six (6) DCFS children were selected for the sample. There were no Probation placed children at the time of the review. PPQA RPM reviewed each child’s files and interviewed them to assess the level of care and services they received. Additionally, three (3) discharged children’s files were reviewed to assess the Contractor’s compliance with permanency efforts.
PPQA RPM reviewed five (5) STRTP staff files for compliance with Title 22 Regulations and County contract requirements. Site visits were conducted to assess the quality of care and supervision provided to the placed children.
PPQA RPM noted findings in the areas of:
Priority 1 • Facility and Environment
o Security bars on the lower half of the facility at Site 1 did not have safetyreleases
• Personnel Fileso Four (4) staff files were missing driver’s licenseso None of the staff had emergency intervention training available to review
Priority 2 • Facility and Environment
o One (1) vehicle was missing the insurance card for vehicleo Common quarters were not well-maintained in that the main bathroom
needed removal of mold and baseboard in activity room needed repairo Sexual Health & Reproductive Rights were not postedo Children’s Bedrooms had areas needing repair
• Needs and Services Plan (NSPs)o Two (2) NSPS were not completed timely, and no NSPs were completed
accurately. One specific NSP contained language not appropriate for thesection, did not have a concurrent case plan, and excluded informationrelated to the progress made. Two (2) NSPs were missing signatures.
• Engagement and Teamwork and Needs and Services Plano CFT notes did not list the adult participants' role in assisting
Each Supervisor April 13, 2021 Page 3 of 4
• Permanency and Transition Serviceso Four (4) files had either missing or inaccurate concurrent case plan goals
• Education and Independent Living Program (ILP) Serviceso Two (2) files had school enrollment issues (delayed or no documentation)o Four (4) files did not have progress reportso Four (4) files did not have documented ILP Services
• Personal Rights Social/Emotional Well-Beingo One (1) child did not know what the Foster Youth Bill of Rights wereo One (1) child was not aware of their specific right to refuse medicationo Two (2) children were not aware of their right to obtain information on safe
sex and reproductive health informationo Two (2) children were not aware of their right to have contraceptives and a
container to lock them in
• Personal Needs/Survival and Economic Well-Beingo Two (2) children were not aware of their allowances or the amounts they
were to receive
• Personnel Fileso No staff files had employment eligibility verification, and one (1) staff did not
have a signed copy of the agency policieso Two (2) staff did not have a signed criminal record statement, two (2) staff
had criminal clearance issues, four (4) staff had medical and TB clearanceissues, four (4) staff files were missing current driver’s licenses and CPRcertifications, and four (4) staff files did not have first aid certifications
o None of the staff had the initial required training and orientationo None of the staff received the required annual ongoing training
Priority 3 • Personal Needs/Survival and Economic Well‐Being
o Two (2) children were not provided with or encouraged/supported by theprovider in keeping a life-book
On December 22, 2020, the PPQA RPM Monitor held an exit conference with the Contractor’s representative.
The Contractor’s representative agreed with the review findings and recommendations and was receptive to implementing systemic changes to improve the Contractor’s compliance with regulatory standards.
Each Supervisor April 13, 2021 Page 4 of 4
The Contractor provided the attached approved Corrective Action Plan (CAP) addressing the noted deficiencies in this compliance report. Many of the CAP elements have been completed or implemented, with continued oversight and technical assistance for the remaining elements.
If additional information is needed or any questions or concerns arise, please contact Director Lisa Campbell-Motton, Placement Permanency and Quality Assurance, at (323) 240-2435.
AG:FC:LCM:cm
Attachment
c: Fesia Davenport, Chief Executive Officer Arlene Barrera, Auditor-Controller Bobby D. Cagle, Director, DCFS Ginger Pryor, Chief Deputy Director, DCFS Public Information Office Audit Committee Sybil Brand Commission Community Care Licensing Division Latasha Howard, Probation Contracts Craig Davis, Director, DeliLu Achievement Home
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DELIANN- LUCILE CORPORATION
5731 W. Slauson Ave Culver City, CA 90230
Phone: 310- 215-8900 Fax: 310-215-8907
Residential Program Monitor and Investigations Unit Lynwood Regional Justice Center 11701 S. Alameda St. 2nd Floor
Lynwood, CA 90262
January 1, 2021
Corrective Action ______________________________________________________________
License Contract requirements
Ⅱ. Facility and Environment
6.2 Area of non-compliance: Site 3 vehicle was missing an insurance card for the vehicle.
Recommendation:
❖ Delilu Achievement Home shall ensure that there is an insurance card in the vehiclebefore transporting clients.
❖ Delilu failed to notify the Administrator Assistant regarding a replacement of theinsurance card due to human error.
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Plan of Action: The Program Supervisor and the Administrative Assistant will ensure that all vehicles operated within Delilu have an insurance card placed within each vehicle. The Facility Managers will be responsible for notifying the Administrator at the site, and the Administrator will inform the Program Supervisor and Administrative Assistant. The Facility Manager will follow up with the Administrator, Program Supervisor one month prior to ensuring the replacement of insurance cards are available.
CAP: The House Administrator will train with the site’s Facility Manager to ensure that they check the vehicle each day during their walk-through.
Quality Assurance Plan: An electronic notification will be placed on the agency’s internet-based calendar. There
will be alerts set to notify the Facility Manager, Administrator, Program Supervisor, and Administrative Assistant via email at both the two-month and one-month dates prior to registration expiration. The administrator and Program Supervisor will ensure these steps are followed by acknowledgment through email. On November 6, 2020, vehicle insurance cards were given to each location. DeliLu has provided a valid registration on 11/06/20.
7.1 Area of noncompliance: Site 2, bedroom 1, had a broken window screen.
Recommendation: Delilu will ensure that all windows and screens are in good condition at all times. A walk-through shall take place at the start of each facility manager shift.
Plan of Action: DeliLu Achievement Home maintenance came to fix the broken window screen. Maintenance repaired the broken window screen on November 10, 2020, at site 2. Utilizing the extra incentive system will encourage the clients to maintain their rooms and report any damages to the Facility Manager. Facility Managers will continue to do a walkthrough around the home and client’s room to ensure it is in excellent condition.
CAP: There shall be a walk through by the Facility Manager at the start of each shift. Any
damages shall be reported immediately for repair. 3
Quality Assurance Plan: Administrators along with the Facility Manager will do a walk-through to ensure that
all exit is clear from objects that could hinder anyone from making a safe exit. If any items are present, they are to be removed immediately.
7.2 Area of non-compliance: Security bars used on windows are equipped with operable safety release. Site 1 Security bars that are only on the lower level do not have safety release.
Recommendation: Due to no security latches on the window bars located downstairs and to be in compliance with the Fire Marshall code and regulation all three emergency exits will be free from debris at all times.
Plan of Action: As staff members conduct their fifteen-minute head check, they will also need to make sure that all emergency exits are free from clutter.
CAP: At the beginning of each shift, the Facility Manager shall walk the facility inside and out and remove any debris from emergency exits.
Quality Assurance: Facility Managers and the Administrator shall do a daily walk-through of the site to ensure all exits are doors are free from objects.
8.12 Area of non-compliance:
Bedroom 1 needed to repair the bathroom faucet. The main bathroom needed to remove mold around the bottom left area of the bathtub.
Recommendation: Delilu Achievement Home will ensure that maintenance issues are reported in a timely manner. DeliLu will make sure that all faucets are walking. Delilu maintenance was sent out to repair the faucet. Site 1 bedrooms 1 needs to repair the bathroom faucet. Delilu Achievement Home will ensure that all bathrooms are clean and in excellent condition for clients to use. Staff will ensure that there is no mold present.
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Plan of Action: DeliLu Achievement Home maintenance came in on November 9th, 2020, to
repair the faucet and remove the mold around the tub within the main bathroom. The facility manager will ensure that staff is cleaning up and reporting all maintenance issues to the Facility Manager and Administrator.
CAP: The Facility Managers on each shift will be responsible for completing the
weekly checklist to ensure the facility complies. At any time there is maintenance that needs to occur, the Facility Manager will reach out to the Administrator so that a work order can be processed. . Quality Assurance: Delilu Achievement Home Program Supervisor and the site Administrator will do a
weekly walk-through to ensure that there are no deficiencies inside and out of the facility..
8.16 Area of non-compliance: Site 3, the baseboard in the activity needs repair.
Recommendation: Delilu Achievement Home will ensure that all maintenance needed within the facility is attended to in a timely manner. Site 3 the baseboard in the activity room needs repair.
Plan of Action: DeliLu Achievement Home maintenance came in on November 9th, 2020, to repair the second floor’s activity room’s baseboard. The Facility Manager will continue to do a
walkthrough within the home and report all the site administrator findings.
CAP: The Facility Manager will conduct a walk-through at the start of their shift and
report any administrator deficiencies. The site Administrator will report this finding to maintenance.
Quality Assurance: There is a maintenance log at each site to keep track of all maintenance issues
within the facility. The Facility Manager is responsible for informing the Administrator of any issue. Administrator will walk through the site to make sure that everything is in good and working order.
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9.4 Area of non-compliance; Site 1 Rights not posted
Recommendation: ( Sexual Health and Reproductive Rights and posted and visible)
Delilu Achievement Home will ensure that Rights are posted around the facility. In a case the poster is not present Administrator ensure that all client information is up and that clients are aware.
Plan of Action DeliLu Achievement Home will ensure that person served has knowledge of their
personal right to sexual health and reproductive rights. The sexual health and reproductive rights were reposted on 12/20/20. The Administrator will make sure all posters are replaced promptly so that all clients are knowledgeable about their rights.
CAP: Delilu will ensure that the staff will go over sexual health and reproductive rights to have
condoms and contraception during the client’s house meeting. The Facility Manager and Administrator will go through a training and curriculum before presenting it to the girls.
Quality Assurance: Administrators and the Facility Manager will ensure that new clients know these rights by posting them around the facility when doing their walk-through.
10.7 Area of non-compliance: Site- 2 bedrooms 3 the beds need tightening, bedroom 1 beds need tightening. Site-3 bedrooms 1 and 3 need to tighten beds.
Recommendation: The Administrator is responsible for conducting a weekly inspection of the site to ensure that everything is in good and working order. Facility Managers will be accountable as will be responsible for completing a weekly inspection with a checklist to ensure the facility is in compliance. Facility Managers will be trained during their monthly meeting with their administrators.
Plan of Action 6
DeliLu maintenance came into both sites on November 10th, 2020, to tighten the beds at sites 2 and 3. Facility Managers will continue to do a walkthrough around the home to ensure everything is in good working order.
CAP: Repaired the beds at each location. Maintenance will check all beds at each site to make
sure they are tight and in good condition.
Quality Assurance: The Facility Manager will conduct a daily walk-through in the facility to ensure that beds and other furniture are in excellent and safe conditions. And all findings
shall be reported to the Administrator and placed on the maintenance log.
10.11 Area of non-compliance: Site 2 bedrooms 2 patches needed for the wall.
Recommendation: Delilu shall ensure that all walls are free from holes and marks. Staff will report any deficiencies to their assigned manager.
Plan of Action Delilu Achievement Home maintenance came in on November 10th, 2020, to patch up the holds/ findings in room two at site 2. The Facility Manager will continue to walk through on a weekly basis to ensure that the home is kept in excellent condition. If there is any deficiency at any time, the Facility Manager will inform the site Administrator to ensure that the issue gets resolved.
CAP: Repaired walls with the facility. Maintenance will check all walls to make sure that there are no damages to the property. The Facility Manager is to report all need maintenance on the maintenance log.
Quality Assurance: The Facility Manager will conduct a daily walk-through at the start of each shift to ensure no damage around the facility. If there are any damages present, they will notify their Administrator and place the details on the facility’s maintenance log.
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Ⅲ. Engagement and Teamwork
16. Area of non-compliance: CFT-3 CFT did not list adult participants’ role in assisting
Recommendation: DeliLu Achievement Home shall ensure that all participants in the CFT meeting are documented.
Plan of Action The Case Manager and the home Administrator will check to see that all participants
have signed to sign in. When the meeting is conducted over Zoom and or Google meet, the Case Manager will reach out to each participant via email in the effort to get all participant’s signatures. DeliLu Achievement will email and call all participants. DeliLu will make three attempts to obtain a signature. If a signature is still not obtained, the case manager and administrator will reach out to the CSW supervisor. DeliLu Achievement Home will document notate the dates and times of correspondence that took place. DeliLu Achievement Home Case Managers, Administrative and Therapist participants in a three-hour training session Child and Family Team (CFT) on September 20, 2020. During that training, Delilu's team learned about the new style of the CFT documentation of a CFT meeting.
CAP: Delilu Achievement shall ensure that all CFT meeting participants sign in by printing and signing their first and last with their title. The case manager will make sure before the meeting is over that all participants signed in.
Quality Assurance: The Case Manager and the Administrator will conduct a check and balance to make sure participants have signed in to the meeting before leaving. The Case Manager and Administrators will be in training on February 10th and 23rd.
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Ⅳ. Needs and Service Plans
16.1 Area of non-compliance: Child 5 was placed on 8/27/20, and her initial NSP was dated 10/28/20
Recommendation:
Delilu Achievement Home shall ensure that NSP’s is developed promptly according to the rule and regulations. The document shall ensure that it is supporting the client’s needs and service plan.
Plan of Action: Administration and Head of Service shall ensure that all NSP is done within the time frame to have the first NSP done. If this can not be done on the part of the case manager, they will need to reach out to the site administrator and or Head of Service for help.
CAP: Delilu Achievement Home shall ensure the timely, comprehensive, initial, and updated NSPs with the developmentally age-appropriate child’s participation.
Quality Assurance: The Administrator and Head of Service will need to make sure that clients NSP is done promptly. Both parties can check-in with the case manager to ensure that the document will be done promptly.
16.2 Area of non-compliance: Child 1 date of placement was missing, no concurrent case plan goal, under-identified
education strength has language that is not appropriate for that section. Child 2 does not have any ILP/life skills documented in the NSP. Child 3 NSP does not list the CSW dates, and there are no ILP/ life skills listed. It does not document any progress. Child 4 cases plan, and concurrent CP both marked PPLA, no CSW dates listed, and no life skills/ILP services. NSP dates 09/23/20 and 10/23/20 no progress reported or updated school information due to covid. Child 5 initial NSP completed late (10/28/20), Child 6 psych meds are marked yes but there is no data of PMA.
Recommendation: 9
Delilu Achievement Home shall ensure the treatment team develops timely comprehensive, initial, and updated NSPs with appropriate language. A life skills binder shall be issued out to all new clients as they enter into our program. The Case Manager and or staff shall conduct a life skill group every week.
Plan of Action: Case Manager shall ensure that each person serves their life skill binder. Case Manager
will make sure all NSP is turned in a timely manager to CSW’s and Head of Service. Case Managers shall also note when CSW’s come on-site to see the clients. The case manager and the Administrator shall ensure a PMA on file for all psych medication. NSP shall be reviewed by the Administrator and Head of Service before it is submitted to the CSW.
CAP: Case Manager shall attend training on documentation and or NSP reporting on
February 23, 2021. Delilu currently does group activities with the clients that deal with life skills. Each location welcomes the girls on various outings to the store, bank, clothing stores, cooking, laundry, healthy eating, etc.
Quality Assurance: The Head of Service shall follow up with case managers every month to ensure NSP’s are
comprehensive. It is the case manager’s responsibility to meet with the child and develop goals with the child. If the Head of Service and or Administrator finds NSP incomplete, she will give a verbal warning with training. If not remediated, then escalated disciplinary action will occur.
16.3 Area of non-compliance:
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Child 2 missing signature page NSP dated 8/11/20, Child 5 missing signature page.
Recommendation: Delilu Achievement Home shall ensure that all parties sign the signature page on their NSP and it is attached.
Plan of Action DeliLu Achievement Home shall ensure all NSP’s have a signature pass attached.
CAP: The Case Manager is assigned to ensure there are signatures present on all documents before any meetings are over.
Quality Assurance: The Case Manager and or Administrator will ensure that signatures are present before the meeting is over. If a signature is missing, it will be up to the case manager to reach out to all participants for a signature.
16.3 Area of non-compliance: Child 2 missing signature page for NSP dated 08/11/20, Child 5 missing signature page.
Recommendation: Case Manager shall ensure that all page of the NSP is there before submitting it to the placement agency. Once a signature has been established, it is the case manager’s responsibility to attach it with the rest of the documents.
Plan of Action: Administrator and the Head of Service shall review all NSP within seven days before the due date is submitted to the placement agency.
CAP: Case Manager shall reach out to the CSW for the signature page is returned promptly. The Case Manager will document all efforts to contact County workers to participate in the NSP and acquire appropriate signatures.
Quality Assurance: Head of Service will follow up every month to ensure timely comprehensive NSP with a
signature.
16.5 Area of non-compliance: CSW. Child 3 missing CSW signatures on all NSPs, Child 4 no CSW signature on NSP dated 8/23 and 10/23. Child 5 missing and 6 missing signatures.
Recommendation: 11
Case Manager shall ensure that all page of the NSP is there before submitting it to the placement agency. Once a signature has been established, the case manager’s responsibility is to attach it with the rest of the documents.
Plan of Action: Administrator and the Head of Service shall review all NSP within seven days before the due date is submitted to the placement agency.
CAP: Case Manager shall reach out to the CSW to ensure the signature page is returned promptly. The Case Manager will document all efforts to contact County workers to participate in the NSP and acquire appropriate signatures.
Quality Assurance: The Head of Service will follow up every month to ensure timely comprehensive NSP with a signature from all CSW’s/DPO’s
Ⅴ. Permanency and Transition Services.
20. Area of non-compliance:Child 1 missing concurrent case plan goal, Child 3 CP goal is FR, but NSP indicates that she will be reunited with sister, Child CP and concurrent CP goal both marked PPLA, Child 5 CP and concurrent CP goal both marked adoption no family finding efforts.
Recommendation: Delilu Achievement Home shall ensure the case manager is implementing the necessary
case notes to support the client. Case Manager shall reach out to CSW and go over any change goal that they may have that was not discussed within the CFT.
Plan of Action: Case Management will continue to be trained on writing NSP. When information is not present when writing the NSP, the case manager will reach out to the placement agency to understand the client’s permanency plan.
CAP: 12
Head of Service shall ensure that NSP is written currently to support the client. If the case manager is not sure about placement goals at any time, he or she shall contact the CSW to gain
clarification.
Quality Assurance: The Head of Service will follow up monthly to ensure timely comprehensive NSP with a signature.
Ⅵ. Education and independent Living Program Services:
27. Area of non-compliance: Child 3 NA school enrollment was delayed due to not having the child's birth certificate
and provided documented efforts to obtain. Child NSP did not provide school enrollment information. Recommendation: Case Manager shall try and reach out to the CSW to obtain the necessary documents to enroll a client into school. Plan of Action:
Delilu Achievement Home site case manager and Administrator shall ensure that all clients placed with our agency shall be enrolled in a school within the first three days of placement. If the school of origin can not be secure at any time, the case manager must reach out to the School Liaison if their SPA is distinct and request assistance in enrolling the client into school. CAP: It is the Administrator’s responsibility to ensure that all clients are enrolled in school. Administrators shall make sure that the client under their care is supported with the right education platform.
Quality Assurance: Administrators shall ensure that once a new client comes into the facility, they enroll in
school within three days of placement. If documentation is needed at any time, it is up to the Case manager to reach out to the CSW for support. Case Manager should also reach out to the school liaison for support. Case Manager shall update all documentation regarding education goals monthly.
29. Area of non-compliance 13
Child 1 was missing a progress report, Child 3was missing a progress report , child5 and 6
missing progress reports.
Recommendation: Case managers shall reach out to the school for the status of each client at the facility. If they are unsuccessful at any time, they will need to reach out to the school liaison for support.
Plan of Action: At any time, Delilu has not received any progress report and or report card. The case manager will reach out to the District Liaison for assistance.
Quality Assurance: Due to COVID, it is tough to obtain documentation from school. However, case managers shall ask for the school liaison’s assistant to track the client’s progress report.
32. Area of non-compliance: Children 1-4, Their NSP’s did not document any ILP services.
Recommendation: Case Manager shall ensure that age-appropriate clients are enrolled in ILP to support them as they get ready to transition out of care.
CAP: Case Manager shall reach out to CSW to obtain the status of an age-appropriate client of the program. During February, the case manager will receive training on conducting information to better support the client. Quality Assurance: Case Manager shall reach out to the client’s CSW to obtain information regarding a client’s ILP status if it is age-appropriate. If such information can not obtain the case manager is to seek the help of the administrator.
Personal Rights and Social/ Emotional Well Being
40. Area of non-compliance:Children 2 did not know what the Foster Youth Bill of Rights was.
Recommendation: Each client shall receive a copy of their right, and it should be discussed within the resident meeting.
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Plan of Action: Upon intake, the case manager or Facility Manager will ensure that the client
is informed of their rights and will be given a printout copy of the Foster Youth Bill of Rights.
CAP: Delilu Achievement Home shall ensure that all informational posters are posted on the wall for view. Quality Assurance: The Facility Manager and Administrator shall ensure a Foster Bill of rights posted throughout the facility. During the resident’s meeting, staff shall go over these rights.
58. Area non -compliance: Child 6 not aware that she could refuse her medication.
Recommendation: DeliLu Achievement Home shall ensure that the clients are aware and given a copy of their rights upon intake.
Plan of Action: Upon intake Case Manager or Facility Manager will inform the client of the medication protocol and the right to refuse medication.
CAP: Once a client has been accepted into our program, the intake packet shall include all client’s personal rights. Quality Assurance: Case Manager, Facility Manager, and Administrator shall ensure that every client has a copy of all of their rights. During their check-in and or conversation shall be stated.
59. Area of non-compliance: Child 2 and child 6 both stated she was not informed of the rights to have contraceptives.
Recommendation: Deliliu Achievement Home shall ensure that each client that enters into the program will
receive a copy of their personal rights that must be signed. The client will need to receive a copy of the signed personal rights document.
Plan of Action: Delilu will continue to remind all persons that they have the right to have contraceptives during placement interviews.
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CAP: Delilu Achievement Home shall ensure that all clients have contraceptives on hand when needed. Such items shall be placed inside of a basket and or box where clients obtain what they need.
Quality Assurance: Case Manager and or Administrator will make sure that clients have access to contraceptives without having to ask. Staff will ensure that the box and or basket is entirely stock for the clients.
64. Area of non-compliance : Child 5 does not have a life book, Child 6 reported that staff does not encourage her to keep a life book. Recommendation: Delilu will ensure that all person served has a brand new life book at the beginning of the year. The Case Manager, Facility Managers, and or Administrator shall have the client’s participant one to two times per week on life skills. Plan of Action: The management team or a designated staff member shall engage clients in working on their
life book. It is the responsibility to do a check and balance to ensure that the work is getting done.
CAP: Delilu Achievement Home shall ensure that each client receives a scrapbook at the time of placement. Quality Assurance Plan: The site case manager will reach out to the Administrator if at any time for a replacement of scrapbooks that need to be purchase. The book should be replaced within five to ten days of notification.
74. Area of non-compliance : Child 3 and 6 are not sure how much they receive for clothing voucher or how often. Recommendation: Deliu Achievement Home will ensure that all clients are aware of the amount each individual receive monthly on a clothing voucher.
Plan of Action: Clients will be notified each month before the voucher is given during their resident meeting.
CAP: Delilu will ensure that each individual is aware of the amount they will receive each month for clothing items.
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Quality Assurance Plan: Delilu will ensure there is a document outlining the amount a client is to receive on a clothing voucher upon intake.
Ⅹ. Personnel Files. . 79. Area of non-compliance: None of the staff had eligibility verification.
Recommendation: ❖ DeliLu’s HR department will create COVID-19 Electronic Document Protocol ❖ DeliLu’s HR department will provide the DPO access to the employee’s personnel files that include eligibility verification documents through a secure and password protected electronic format that protects the employee’s confidentiality and provides security and safety to all parties until the COVID-19 pandemic emergency restrictions are lifted and physical access to files do not create a threat of exposure to the COVID-19 virus.
Plan of Action: In the interim of COVID-19 and the high risk of surface exposure; the Dept. of Probation will have access to documents requested through secure electronic access that is password protected, easily accessible, and readily available in line with the Program Statement and governing regulations. We will provide access through online cloud storage.
CAP: Employee personnel files must have all required and current documents in their files including their eligibility verification, experience and/or qualifications requirements and exemptions in accordance with the agency’s program statement and governing regulations.
Quality Assurance Plan: ❖ The HR department will create new electronic access COVID-19 Protocol In lieu of
physical access to documents; access to a secure online cloud storage that contains the “employee verification” documents will be made available.
❖ The quality assurance measures that will be implemented to maintain compliance include internally auditing all new hire documents before, during, and after they are hired for missing documents to ensure the file is compliant with the Program Statement and governing regulations before they are allowed onsite or by children.
❖ Current employee files will be audited, updated, and reviewed every 3 months to ensure that all documents meet the Program Statement and governing regulations.
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79.2 Area of non-compliance: Staff 1 did not have a signed copy of the agency policies, including confidentiality agreement and mandated reporter acknowledgment
Recommendation: ❖ DeliLu Achievement Home will provide the DPO access to the employee’s personnel files
that will include Staff 1’s “agency policies, including confidentiality agreement and mandated reporter acknowledgment.” through a secure and password protected electronic format that protects the employee’s confidentiality and provides security and safety to all parties until the COVID-19 pandemic emergency restrictions are lifted and physical access to files do not create a threat of exposure to the COVID-19 virus.
Plan of Action: Staff 1’s employee’s personnel file will be upload and audit ensure all documents are available and signed in accordance with the Program Statement and agency’s regulations.
CAP: The Dept. of Probation will be provided with immediate access to Staf 1’s “agency policies, including confidentiality agreement and mandated reporter acknowledgment” documents. These files will be provided through a secured cloud drive that is password protected, easily accessible, and readily available in line with the Program Statement and governing regulations. We will provide access through online cloud storage.
Quality Assurance Plan:
❖ Create new electronic access COVID-19 Electronic Document Protocol ❖ Current employee files will be audited, updated, and reviewed every 3 months to ensure that
all documents meet the Program Statement and governing.
80.1 Area of non-compliance: Staf 1 and 2 did not have a signed criminal record statement.
Recommendation: ❖ DeliLu Achievement Homes will improve their employee filing system to include a secure online database that they can provide temporary secure access to regulatory partners. ❖ Each employee’s file will be audited to ensure that their documents are in the file and up to date.
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Plan of Action: Provide the DPO access to the employee’s personnel files that will include Staf 1 and Staf 2’s “signed criminal record statement” through a secure and password protected electronic format that protects the employee’s confidentiality and provides security and safety to all parties until the COVID-19 pandemic emergency restrictions are lifted and physical access to files do not create a threat of exposure to the COVID-19 virus.
CAP: The Dept. of Probation will be provided with immediate access to Staf 1 and 2’s “signed criminal record statement” documents. These files will be provided through a secured cloud drive that is password-protected, easily accessible, and readily available in line with the Program Statement and governing regulations. We will provide access through online cloud storage.
Quality Assurance Plan: ❖ Create new electronic access COVID-19 Electronic Document Protocol ❖ Current employee files will be audited, updated, and reviewed every 3 months to ensure that
all documents meet the Program Statement and governing.
80.2 Area of non-compliance: Staf 1 criminal clearance was blank. Staf 2 did not have a criminal clearance available for review
Recommendation:
❖ DeliLu Achievement Homes will improve their employee collection and filing system to include a secure online database that can provide temporary secure access to regulatory partners.
❖ Each employee’s file will be audited to ensure that their documents are in the file and up to date.
Plan of Action:
Staf 1 and 2’s personnel files will include “evidence of criminal background clearance with a printout from the new Guardian System indicating the date and agencies where clearance was granted.” The Dept of Probation will be provided secure access to the documents.
CAP: Staff 1 and 2’s evidence of criminal clearance will be provided to the Dept. of Probation through a secured cloud database.
Quality Assurance Plan:
Current staff/employee files will be audited quarterly (every three months) to ensure that all documents meet the Program Statement and governing regulations.
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81.1 Area of non-compliance: Staff 1, 3,4, and 5 did not have a medical clearance available for review
Recommendation: ❖ Currently there isn’t a protocol to ensure that employees files are easily accessible to the
regulatory agencies. Creation of a COVID-19 protocol which provides a mean for theDepartment of Probation to access employee files through a secured cloud system isrequired.
Plan of Action: Develop a protocol for checking to ensure all Staff who has contact with the residents have all their medical clearances in the file and updated in accordance with CCLD and other regulatory agencies.
CAP: Provide the DPO access to the employee’s personnel files that will include Staff 1, 3, 4, and 5’s “medical clearance form LIC508” through a secure and password protected electronic format that protects the employee’s confidentiality and provides security and safety to all parties until the COVID-19 pandemic emergency restrictions are lifted and physical access to files do not create a threat of exposure to the COVID-19 virus.
Quality Assurance Plan: ❖ Create new electronic access COVID-19 Protocol❖ Document and attain from all new hire’s their medical clearance form LIC508 that
indicates clearance within 1 year prior to hiring date or within seven days after hire dateo Current employee files will be audited, updated, and reviewed every 3 months toensure that Medical Clearance is updated to meet the Program Statement and governing.
81.2 Area of non-compliance: Staff 1, 3, 4 and 5 did not have a TB clearance available for review
Recommendation: ❖ Currently there isn’t a protocol to ensure that employees files are easily accessible to the
regulatory agencies. Creation of a COVID-19 protocol which provides a mean for theDepartment of Probation to access employee files through a secured cloud system isrequired.
Plan of Action:
❖ Provide the DPO access to the employee’s personnel files that will include Staff 1, 3, 4, and 5’s “TB clearance” through a secure and password protected electronic
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format that protects the employee’s confidentiality and provides security and safety to all parties until the COVID-19 pandemic emergency restrictions are lifted and physical access to files do not create a threat of exposure to the COVID-19 virus.
CAP: Staff 1,3,4, and 5’s “TB Clearance” documents will be provided to the Department of Probation by secured online cloud storage.
Quality Assurance Plan: ❖ DeliLu Achievement Homes will create new electronic access COVID-19
Protocol ❖ Document and attain from all new hire’s their TB clearance that indicates clearance within 1 year prior to hiring date or within seven days after hire date ❖ Current employee files will be audited, updated, and reviewed every 3 months to ensure that TB clearance is updated to meet the Program Statement and
governing.
82.2 Area of non-compliance: Staff 1,2,3 and 5 did not have a driver’s license available for review
Recommendation: ❖ DeliLu Achievement Homes will improve their employee filing system to include a secure
online database that can provide temporary secure access to regulatory partners. Each employee’s file will be audited to ensure that their documents are in the file and up to date.
Plan of Action: ❖ Provide the DPO access to the employee’s personnel files that will include Staff 1, 2, 3,
and 5’s “Valid and Current Driver’s License” through a secure and password protected electronic format that protects the employee’s confidentiality and provides security and safety to all parties until the COVID-19 pandemic emergency restrictions are lifted and physical access to files do not create a threat of exposure to the COVID-19 virus.
CAP: Staff 1,2,3, and 5’s copies of their “current and valid Driver’s License” will be provided to the Department of Probation by secured online cloud storage.
Quality Assurance Plan:
❖ DeliLu Achievement Home will create electronic access COVID-19 Protocol 21
❖ DeliLu Achievement Home will document and attain from all new hires a copy of their Current and Valid License, Certificates, and DMV printout of Driver’s Vehicle License record prior to the hiring date
❖ DeliLu Achievement Home will audit employee files on the anniversary of their DOB to check status of California Driver License
❖ DeliLu Achievement Home will audit the staff files to make sure they provide a Copy of their DMV printout on the anniversary of their DOB.
❖ Current employee files will be audited, updated, and reviewed every 3 months to ensure that Current and Valid License, Certificates, and DMV printout of Driver’s Vehicle License records are updated to meet the Program Statement and governing.
82.3 Area of non-compliance: Staff 1,3,4, and 5’s did not have a current CPR & First Aid certificate available for review
Recommendation: ❖ DeliLu Achievement Homes will improve their employee filing system to include a secure
online database that can provide temporary secure access to regulatory partners. Each employee’s file will be audited to ensure that their documents are in the file and up to date.
Plan of Action: Provide the DPO access to the employee’s personnel files that will include Staff 1,3,4, and 5’s “Current CPR and First Aid Certificate,” through a secure and password protected electronic format that protects the employee’s confidentiality and provides security and safety to all parties until the COVID-19 pandemic emergency restrictions are lifted and physical access to files do not create a threat of exposure to the COVID-19 virus.
CAP: Staff 1,3,4, and 5’s copy of their “current CPR and First Aid certificate” will be provided to the Department of Probation by secured online cloud storage.
Quality Assurance Plan: ❖ DeliLu Achievement Home will create electronic access COVID-19 Protocol ❖ DeliLu Achievement Home will document and attain from all new hires a copy of their CPR and First Aid Certificates prior to hiring date ❖ DeliLu Achievement Home will audit employee files for their CPR and First Aid
Certificates annually to meet the Program Statement and governing. 22
83.1 Area of non-compliance: None of the staff have emergency intervention training available for review
Recommendation:
❖ DeliLu Achievement Homes will improve their employee filing system to include a secure online database that can provide temporary secure access to regulatory partners. Each employee’s file will be audited to ensure that their documents are in the file and up to date. This includes providing access to Employee’s Training Certificates and Training Plan. DeliLu Achievement Homes conducts TCI training with Dr. Finkelstein annually. The certificate of completions will be provided to the Dept. of Probation when requested.
Plan of Action: Provide the DPO access to the employee’s individual training plans that will include all the staff’s proof of the employee’s “TCI Completion Certificates,” through a secure and password protected electronic format that protects the employee’s confidentiality and provides security and safety to all parties until the COVID-19 pandemic emergency restrictions are lifted and physical access to files do not create a threat of exposure to the COVID-19 virus.
CAP: All Staff’s copy of their “current TCI training completion certificates” will be provided to the Department of Probation by secured online cloud storage.
Quality Assurance Plan: ❖ Annually document proof from employees of Emergency Intervention Training Certificates (TCI Training) are, in electronic personnel files and physical files. ❖ Audit update of attendance and completion of Emergency Intervention Training annually. ❖ Staff training files will be audited, updated, and reviewed every 3 months to ensure
that all required staff has received or completed the mandatory Emergency Intervention Training in accordance with the Program Statement and governing.
83.2 Area of non-compliance: None of the staff had 24 hours of initial training for review
Recommendation: 23
❖ DeliLu will provide the copy of all staff’s training book which will include proof of completion of the initial 24 hours training in accordance with CCLD and other regulatory agencies.
Plan of Action: Provide the DPO access to the employee’s individual training plans that will include all the staff’s proof of the employee’s “24-hour Initial Training Completion,” through a secure and password protected electronic format that protects the employee’s confidentiality and provides security and safety to all parties until the COVID-19 pandemic emergency restrictions are lifted and physical access to files do not create a threat of exposure to the COVID-19 virus.
CAP: All Staff’s copy of their “Initial 24-hour New Hire training completion certificates” will be provided to the Department of Probation by secured online cloud storage.
Quality Assurance Plan: ❖ Document proof from employees of 24- Hour Initial Training Certificates are, in
electronic personnel files and physical files. ❖ Audit update of attendance and completion of 24-Hour Initial training at a maximum
of 90 days after hire. ❖ Staff training files will be audited, updated, and reviewed to ensure that all required
staff has received or completed the mandatory 24-hour initial training in accordance with the Program Statement and governing.
83.3-84.8 Area of non-compliance:
No record was provided of staff’s training records which include initial and ongoing trainings on the following topics:
1-hour child abuse and reporting CSEC LGBTQ 8 hours of Reproductive and Sexual Health 2-Hours of Developmentally Disable Children TCI or Emergency Intervention Training 40 hours of on-going training
Recommendation: 24
❖ DeliLu Achievement Homes to provide Dept of Probation with copies of Annual Training Plan and records of Certificate of Completion.
Plan of Action: ❖ Provide the DPO access to the Staff’s Training files that will include all Staff’s
initial, on-going, and annual training certificates, through a secure and password protected electronic format that protects the employee’s confidentiality and provides security and safety to all parties until the COVID-19 pandemic emergency restrictions are lifted and physical access to files do not create a threat of exposure to the COVID-19 virus.
❖ DeliLu will provide proof of completion of staff’s initial and on-going training on the following topics:
o 1-hour child abuse and reporting o CSEC o LGBTQ o 8 hours of Reproductive and Sexual Health o 2-Hours of Developmentally Disable Children o TCI or Emergency Intervention Training o 40 hours of on-going training
CAP: All Staff’s initial, ongoing, and annual training completion certificates and Annual Training Plan will be provided to the Department of Probation by secured online cloud storage.
Quality Assurance Plan: ❖ All Staff individual Training Plans will be audited and placed in the electronic
personnel files and physical files. ❖ Audit update of attendance and completion of training received monthly. ❖ Staff training files will be audited, updated, and reviewed to ensure that all required staff training is being completed in accordance with the Program Statement and governing.
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Print Name:Jameka Johnson Signature: ___________________________
Date: 02-04-2021
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